Lung Cancer.pdf

242 A.A. Vaporciyan, J.F. Kelly, and K.M.W. Pisters
ful patient selection and close cooperation between the various members of
the multidisciplinary team are requirements for successful multimodality
therapy. Every member of the multidisciplinary team must be aware of the
effects of each treatment modality on the delivery of subsequent treatments.
Close collaboration between members of the team helps to ensure
that any possible problem will be addressed early, before it can progress to
cause irreversible morbidity or a delay in the delivery of planned therapy.
Multimodality regimens involving chemotherapy should only be used
in patients with a Zubrod performance status score of 0 or 1 and adequate
bone marrow, liver, and kidney function. The addition of chemotherapy to
radiation therapy increases the frequency and severity of the most common
acute radiation-induced side effects—esophagitis, skin reactions,
pneumonitis, and pericarditis. In patients with unresected disease treated
with chemotherapy and definitive radiation therapy, severe esophagitis
occurs in approximately one third of patients treated with a sequential approach
(chemotherapy followed by radiation therapy) and approximately
two thirds of patients treated with a concurrent approach. Symptomatic
relief with analgesics and nutritional support are the mainstays of treatment
for patients with severe esophagitis. Preoperative radiation therapy
and, to a lesser extent, preoperative chemotherapy increase the risk of surgery-related
complications, including wound infections and dehiscence,
persistent air leak, and bronchopleural fistula. The use of meticulous dissection,
reinforced staple lines, and pulmonary sealants can reduce the incidence
of parenchymal air leaks, while the use of rotational flaps, such as
intercostal muscle flaps and pericardial fat pad flaps, can limit problems
with the bronchial closure.
Introduction
In certain subsets of patients with non–small cell lung cancer (NSCLC),
multimodality therapy is more effective than single-modality therapy in
reducing the incidence of tumor recurrence and improving overall survival.
Today, many patients with NSCLC are treated with a multimodality
approach. However, the combination of several different treatment
modalities, each associated with particular side effects, can lead to increased
overall morbidity. To successfully implement this aggressive form
of treatment, clinicians must understand the risks inherent in the treatment
plan and the available methods for minimizing these risks and managing
any side effects that occur. Each discipline involved in the care of patients
with NSCLC (medical oncology, radiation oncology, and thoracic
surgery) will have its own set of concerns depending on the order in
which the treatment modalities are administered.
At M.D. Anderson Cancer Center, all possible permutations of the 3
standard modalities of therapy (chemotherapy, surgery, and radiation